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Next Step: Health Plan Information

Complete the following fields based on the member whose service was denied.

* indicates a required field.

Required Documents

What Information Do I Need to Request a Review? 

  • A denial letter from your health plan, known as a 'Final Adverse Benefit Determination Letter'. This is the letter you received from your health plan after you requested an internal review. 
  • Your insurance card
  • Any relevant medical records or supporting materials to help demonstrate why the service, treatment, or item should be covered
  • A physician certification form 
  • Member Representative Information - if you choose to have someone represent you in this appeal, you will need their information. 

If you are requesting an Expedited Independent External Review, you must also submit a Physician Certification Form, a document completed by your doctor. 

Personal Details

Provide legal guardian’s name, if applicable.

Home Address

Contact Information

By selecting this box, I agree to receive notification of eligibility for independent external review and Independent Review Organization assignment by email rather than paper mail.

Next Step: Decision Dispute

* indicates a required field.

This information will be used to confirm your eligibility for an independent external review.

This number is listed on the front of the membership identification card provided to you by your insurance provider. If you have difficulty locating this number, please contact your health insurance provider.

This number will be provided in response to the internal appeal you submitted to your health insurance. If you have not requested an appeal directly from your insurance provider, you must do so before requesting an Independent External Review.

Insurance Card File Upload (Optional)

 We recommend you upload images of your insurance card (Front and Back) to ensure accurate processing.

Upload Images

All files must be uploaded using the correct formats, and must be less than 2MB/file in size. Files over 2MB should be split into smaller files and uploaded separately.



Acceptable Formats:

  • Images: .jpg, .jpeg, .png, .gif, .webp, .HEIC(Apple iPhones).
  • Documents: .pdf, .doc, .docx, .ppt, .pptx, .pps, .ppsx, .odt, .xls, .xlsx, .PSD, .rft.

  

    Next Step: In Your Own Words

    * indicates a required field.

    The information below is needed for your insurer to match your request for independent external review to the correct claim.

    This is the date you received notice that the service, treatment, or item will not be covered by your insurance provider.

    You may be eligible to receive a faster decision when your life, health, or ability to regain maximum function would be jeopardized by the standard 45-day review.

    *If yes, have your provider complete the physician certification and include with request.

    Physician Certification

    Once your doctor has completed the Physician Certification Form, you must upload the document to include with your request.

    A Physician Certification is a document completed by your doctor that confirms that your life or health is in serious risk without the requested service, treatment, or item. This document is required for Expedited Independent External Reviews, a process that reduces the wait time for a decision to be issued

    Upload Files

    All files must be uploaded using the correct formats, and must be less than 5MB/file in size. Files over 5MB should be split into smaller files and uploaded separately.


    Acceptable Formats:

    • Images: .jpg, .jpeg, .png, .gif, .webp, .HEIC(Apple iPhones).
    • Documents: .pdf, .doc, .docx, .ppt, .pptx, .pps, .ppsx, .odt, .xls, .xlsx, .PSD, .rft.

    Drag and Drop To Upload

      Healthcare Provider Information

      Healthcare Provider Mailing & Contact Info

      Next Step: Member Representation

      * indicates a required field.

      Description of Disagreement

      In your own words, describe why you disagree with your insurer's decision. Please include any details that you feel may help us understand your unique situation. If needed, use the attachments upload option below to include additional documents.

      Do not include any sensitive information, such as a Social Security number.

      Additional Explanation

      For explanation longer than 500 characters attached any additional pages.

      Upload Files

      All files must be uploaded using the correct formats, and must be less than 3MB/file in size. Files over 3MB should be split into smaller files and uploaded separately.


      Acceptable Formats:

      • Images: .jpg, .jpeg, .png, .gif, .webp, .HEIC(Apple iPhones).
      • Documents: .pdf, .doc, .docx, .ppt, .pptx, .pps, .ppsx, .odt, .xls, .xlsx, .PSD, .rft.

        

        Next Step: Review and Submit

        * indicates a required field.

        Fill out this section ONLY if someone will be representing you In this appeal. Otherwise, skip and continue.

        You can have a family member, friend, lawyer, or other person represent you or act on your behalf. You or your representative may ask your insurer to see any information your insurer has about the medical service(s) that is the subject of your independent external review.

        Send documents to:

        Authorized Representative Information

        I hereby authorize this person to pursue this external review on my behalf.

        Authorized Representative Address

        Authorized Representatives Contact Info

        Please review your information carefully before you submit.

        Consent to Release & Exchange Information *

        By submitting this form, you hereby request an external review of an adverse benefit determination. I authorize the Pennsylvania Insurance Department and an independent external review organization certified by the Department to obtain copies of my medical records and all other information necessary for this review.  The Department, my health insurer, and my providers have my permission to release and exchange this information with the independent review organization, and with any health care provider or personal representative designated on this application form.

        Selecting the checkbox below will serve as your electronic signature.

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